Provider Demographics
NPI:1669582391
Name:PARHAM, JACK
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:PARHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5669 NW 99TH LN
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33076-2833
Mailing Address - Country:US
Mailing Address - Phone:954-575-5909
Mailing Address - Fax:
Practice Address - Street 1:900 NW 13TH ST STE 305
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-2350
Practice Address - Country:US
Practice Address - Phone:561-750-7633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT17345OtherLICENSE #